Shingles, is caused by the reactivation of the varicella-zoster virus (VZV), the same virus that causes varicella (chickenpox). The chicken pox virus, varicella zoster, remains dormant in nerve roots of dorsal root ganglia, located in spinal cord, and ganglia of trigeminal nerve for decades. The virus can be reactivated with aging, immune insufficiency, illness, and/or stress; however, the exact cause of the reactivation of varicella zoster virus causing shingles is not known. The varicella-zoster virus will destroy the neurons in the ganglion nerve to replicate and spread causing pain (Dunphy, Winland-Brown, Porter, Thomas, 2015). The pain from the destruction of ganglion nerves is often the first symptom of shingles before a rash occurs. Vesicular lesions appear from the virus spreading through nerves to dermatome (Dunphy et al., 2015). Shingles typically occur in one nerve at a time. The pain associated with the destruction of the ganglion can be excruciating. Postherpetic neuralgia can be diagnosed in patients who have persistent refractory pain after treatment of shingles (Hadley et al., 2016). The pain from the damaged nerve root may persist although treatment is no longer needed. Patients will experience chronic pain that will need to be managed on an individual basis.
Incidence and Prevalence:
Exactly what triggers this reactivation has not yet been determined precisely. External re-exposure to the virus, acute or chronic disease processes particularly malignancies and infections, medications and stress are some of the risk factors (Kawai & Yawn, 2017).
Anyone who has had the chickenpox is at risk for contracting shingles. The Center for Disease Control and Prevention estimated that one out of every three people will develop shingles in their lifetime and there were approximately 1 million people diagnosed and treated for shingles in 2016 (Zawada & Baptista, 2013). The risk for developing shingles increases in older adult populations greater than 60 years of age.
About 10 to 15% of people who get shingles will experience Post Herpetic Neuralgia (PHN). The risk of PHN increases with age. The cause of PHN also remains a mystery. Rapid initiation of treatment decreases the incidence of PHN substantially (Friesen, Chateau, Falk, Alessi-Severini & Bugden, 2017). Children can get shingles, but it is not common. Shingles is increasing among adults in the United States. The increase has been gradual over a long period of time.
Physical assessment and examination:
Patients should first have a thorough history taken in order to definitively diagnose them with shingles. The patient should be asked about pain characteristics. If the patient describes more frequent pain at night and increased pain with temperature changes those are signs of possible shingles. Patients should be asked when pain begins and if they have any changes in vision or hearing because the virus can be dormant in ganglion in the ears and eyes. If they have changes in vision, they should be immediately referred to an ophthalmologist.
Assessment of the mouth, back, ears, and head for rashes is imperative. Often the initial rash will appear as erythema, then change to a papular lesion forming a vesicle (Dunphy et al., 2015). Lesions and skin changes may not appear until 2-3 days following pain initiation. Patients can have assay tests and titer tests performed for definitive diagnosis; however, diagnosis is based more off assessment and symptoms.
Education and Treatment Plan:
Patients should be placed on antiviral medications (acyclovir) to treat varicella zoster and also placed on pain medications as needed. Patients should be educated to take medications as prescribed to ensure adequate treatment and better outcomes. Antivirals can be taken with food to avoid complications associated upset stomach. Patients should be encouraged to notify provider before stopping medications for complications.
Education on the spread of the virus is very important. Vesicles that are open without crusts can spread the infection to others. Patients should be educated to avoid contact with children who have not been vaccinated against chickenpox or individuals who have not yet had chickenpox. They should also avoid contact with pregnant women and individuals with weakened immune systems. Patients should try to avoid scratching lesions because of risk for infection. Patients who are not immunocompromised can be given a vaccine known as Zostavax to prevent postherpetic neuralgia.
Management and follow-up:
It is imperative for medical staff to manage healed vesicles and continue to assess them. Pain relief must continue to be assessed to ensure that chronic nerve pain is not occurring. Patients can be encouraged to use calamine lotions to soothe lesions and prevent scratching that can cause infection. Medications such as gabapentin can be used to treat chronic neuralgia pain.
Follow up appointments should be made to assess lesions, pain, and need for further referrals. If the patient has eye pain from damaged ganglion in an ophthalmic area a referral for an ophthalmologist should be made. A referral may also be required to pain centers if chronic neuralgic pain continues after treatment of shingles.
Dunphy, M. L., Winland-Brown, J., Porter, B., Thomas, D., (2015). Primary Care the Art and Science of Advanced Practice Nursing. Philadelphia, PA: F.A. Davis Company.
Hadley, G. R., Gayle, J. A., Ripoll, J., Jones, M. R., Argoff, C. E., Kaye, R. J., & Kaye, A. D. (2016). Post-herpetic Neuralgia: A Review. Current Pain and Headache Reports, 20(3). doi:10.1007/s11916-016-0548-x
Kawai, K., & Yawn, B. P. (2017). Risk Factors for Herpes Zoster: A Systematic Review and Meta-analysis. Mayo Clinic Proceedings, (12), 1806. doi:10.1016/j.mayocp.2017.10.009
Zawada, W. P., & Baptista, V. M. (2013). Shingles. Magill’S Medical Guide (Online Edition).